Provider Demographics
NPI:1447211818
Name:VAN UMMERSEN, LYNN (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:VAN UMMERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIAL DEPARTMENT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-432-8339
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:765 IMAGE WAY
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8399
Practice Address - Country:US
Practice Address - Phone:386-774-7411
Practice Address - Fax:386-774-7412
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL99045207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000924400Medicaid
F91487Medicare UPIN
FLBT551YMedicare PIN
WI058715875Medicare ID - Type Unspecified